Innovations in Oncology Management
PART 4 OF A SERIES
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Working Collaboratively with Payer Organizations
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s the national debate about the rising cost of healthcare STAKEHOLDER PERSPECTIVE continues, government projections indicate that healthcare spending will account for nearly 20% of the American Engaging with Local Payers: economy in 2021.1,2 Cancer care is an important contributor to The Oncology Practice this trend; in fact, oncology costs are expected to increase by 38%, 3 Perspective.................................. 6 from $125 billion in 2010 to a projected $173 billion in 2020. An Interview with Dawn Holcombe, MBA, Because of the escalating cancer-related costs, some individuals are B:8.375” FACMPE, ACHE, President, DGH concerned that high-quality cancer care may become too expenConsulting, South Windsor, CT; Executive T:8.125” 4 sive for many Americans in the future. Director, Connecticut Oncology Association, S:7.625” Rising cancer costs can be attributed in part to tremendous clinical South Windsor, CT innovations that have taken place in oncology during the past 2 decades, with breakthrough drugs and technologies that have extended patients’ lives, improved their quality of life, and, in some cases, even numerous factors, including failures of care delivery, failures of care cured their cancer.5 Major clinical advances are the culmination of coordination, overtreatment, administrative complexity, pricing years of expensive, time-consuming research and development, and failures, and fraud and abuse.2 they represent only a fraction of the investigational therapies that are It has been estimated that more than 33% to nearly 50% of US assessed each year in preclinical studies and in clinical trials.5 healthcare spending is wasted, and medical experts believe that Clinical innovation notwithstanding, the United States spends the majority of this total, if not all of it, could be saved without 2.5 times more per capita on healthcare than do other developed affecting patients’ quality of care.2 In recent years, health policy countries, suggesting that there is a substantial amount of waste and efforts have focused largely on ways to save costs and build efficieninefficiency in our healthcare system.6 This can be attributed to cies without sacrificing innovation and quality.7
Editor’s Note Welcome to Innovations in Oncology Management, a news- ity of care. Such collaborative efforts include the development of letter series developed for oncology practice administrators, clinical pathways or protocols and comprehensive care initiatives. There are also steps that oncology practices can take to proadministrative staff, advanced practice clinicians, and oncology pharmacists. The series offers current and relevant information actively work with payers toward the ultimate goal of efficient, patient-centered treatment. In a compelling interview, Dawn on issues that are impacting the business of oncology. The fourth in the series, this newsletter discusses initiatives and Holcombe, MBA, FACMPE, ACHE, discusses the current programs among payers, providers, and pharmacies to contain healthcare landscape and offers suggestions on how payers and rising costs while improving the quality of healthcare. Clinical practices can work together successfully toward common goals. Previous newsletters in this series have explored a variety of variations in how physicians treat patients and utilize healthcare resources in the United States have become a source of inefficien- topics, and installments of these newsletters can be found at cy. The need is consequently growing for processes that encour- www.innovationsinoncologymanagement.com. The next series age consistency and reduce the use of treatments that deviate in Innovations in Oncology Management will feature the followfrom evidence-based guidelines. Collaborative efforts between ing topics: navigating payer audits, coordinating with specialty healthcare providers, payers, and even pharmacies may improve pharmacies, best practices in oncology leadership, and navigatPatients, Science, andwithout Innovation are thepatients’ foundation the efficiency of healthcare compromising qual- of ingeverything external legislative and policy directives.
we do. At Celgene, we believe in an unwavering commitment to medical innovation, from discovery to development. Our passion is relentless—and we are just getting started. Supported by funding from Celgene Corporation and Celgene Patient Support. Manufacturer did not influence content.
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Innovations in Oncology Management
PART 4 OF A SERIES
http://innovationsinoncologymanagement.com
TM
Working Collaboratively with Payer Organizations
A
s the national debate about the rising cost of healthcare continues, government projections indicate that healthcare spending will account for nearly 20% of the American economy in 2021.1,2 Cancer care is an important contributor to this trend; in fact, oncology costs are expected to increase by 38%, from $125 billion in 2010 to a projected $173 billion in 2020.3 Because of the escalating cancer-related costs, some individuals are concerned that high-quality cancer care may become too expensive for many Americans in the future.4 Rising cancer costs can be attributed in part to tremendous clinical innovations that have taken place in oncology during the past 2 decades, with breakthrough drugs and technologies that have extended patients’ lives, improved their quality of life, and, in some cases, even cured their cancer.5 Major clinical advances are the culmination of years of expensive, time-consuming research and development, and they represent only a fraction of the investigational therapies that are assessed each year in preclinical studies and in clinical trials.5 Clinical innovation notwithstanding, the United States spends 2.5 times more per capita on healthcare than do other developed countries, suggesting that there is a substantial amount of waste and inefficiency in our healthcare system.6 This can be attributed to
STAKEHOLDER PERSPECTIVE Engaging with Local Payers: The Oncology Practice Perspective................................... 6
An Interview with Dawn Holcombe, MBA, FACMPE, ACHE, President, DGH Consulting, South Windsor, CT; Executive Director, Connecticut Oncology Association, South Windsor, CT
numerous factors, including failures of care delivery, failures of care coordination, overtreatment, administrative complexity, pricing failures, and fraud and abuse.2 It has been estimated that more than 33% to nearly 50% of US healthcare spending is wasted, and medical experts believe that the majority of this total, if not all of it, could be saved without affecting patients’ quality of care.2 In recent years, health policy efforts have focused largely on ways to save costs and build efficiencies without sacrificing innovation and quality.7
Editor’s Note Welcome to Innovations in Oncology Management, a newsletter series developed for oncology practice administrators, administrative staff, advanced practice clinicians, and oncology pharmacists. The series offers current and relevant information on issues that are impacting the business of oncology. The fourth in the series, this newsletter discusses initiatives and programs among payers, providers, and pharmacies to contain rising costs while improving the quality of healthcare. Clinical variations in how physicians treat patients and utilize healthcare resources in the United States have become a source of inefficiency. The need is consequently growing for processes that encourage consistency and reduce the use of treatments that deviate from evidence-based guidelines. Collaborative efforts between healthcare providers, payers, and even pharmacies may improve the efficiency of healthcare without compromising patients’ qual-
Supported by funding from Celgene Corporation and Celgene Patient Support. Manufacturer did not influence content.
ity of care. Such collaborative efforts include the development of clinical pathways or protocols and comprehensive care initiatives. There are also steps that oncology practices can take to proactively work with payers toward the ultimate goal of efficient, patient-centered treatment. In a compelling interview, Dawn Holcombe, MBA, FACMPE, ACHE, discusses the current healthcare landscape and offers suggestions on how payers and practices can work together successfully toward common goals. Previous newsletters in this series have explored a variety of topics, and installments of these newsletters can be found at www.innovationsinoncologymanagement.com. The next series in Innovations in Oncology Management will feature the following topics: navigating payer audits, coordinating with specialty pharmacies, best practices in oncology leadership, and navigating external legislative and policy directives.
PUBLISHING STAFF Senior Vice President/Group Publisher Nicholas Englezos nenglezos@the-lynx-group.com Vice President/Group Publisher Russell Hennessy rhennessy@the-lynx-group.com Publisher Cristopher Pires cpires@the-lynx-group.com Vice President/Director of Sales & Marketing Joe Chanley jchanley@the-lynx-group.com Director, Client Services Zach Ceretelle zceretelle@the-lynx-group.com Editorial Directors Dalia Buffery dbuffery@the-lynx-group.com Anne Cooper acooper@the-lynx-group.com Editorial Assistant Cara Guglielmon Senior Production Manager Lynn Hamilton The Lynx Group President/CEO Brian Tyburski Chief Operating Officer Pam Rattananont Ferris Vice President of Finance Andrea Kelly Human Resources Jennine Leale Director, Strategy & Program Development John Welz Director, Quality Control Barbara Marino Quality Control Assistant Theresa Salerno Director, Production & Manufacturing Alaina Pede Director, Creative & Design Robyn Jacobs Creative & Design Assistants Lora LaRocca Wayne Williams Jr Digital Media Specialist Charles Easton IV Web Content Manager Anthony Trevean Digital Programmer Michael Amundsen Meeting & Events Planner Linda Mezzacappa Project Managers Deanna Martinez Jeremy Shannon Project Coordinator Rachael Baranoski IT Manager Kashif Javaid Administrative Team Leader Allison Ingram Administrative Assistant Amanda Hedman Office Coordinator Robert Sorensen Engage Healthcare Communications, LLC 1249 South River Road - Ste 202A Cranbury, NJ 08512 phone: 732-992-1880 fax: 732-992-1881
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EDITOR’S NOTE Welcome to Innovations in Oncology Management ™.......................................1
FEATURE Working Collaboratively with Payer Organizations...................................... 1
STAKEHOLDER PERSPECTIVE Engaging with Local Payers: The Oncology Practice Perspective An Interview with Dawn Holcombe, MBA, FACMPE, ACHE, President, DGH Consulting, South Windsor, CT; Executive Director, Connecticut Oncology Association, South Windsor, CT................................ 6
MISSION STATEMENT Oncology healthcare requires providers to focus attention on financial concerns and strategic decisions that affect the bottom line. To continue to provide the high-quality care that patients with cancer deserve, providers must master the ever-changing business of oncology. Innovations in Oncology Management ™ offers process solutions for members of the cancer care team—medical, surgical, and radiation oncologists, as well as executives, administrators, and coders/billers—including patient financial support services, health policy legislation, and emerging payment models.
Innovations in Oncology Management ™ is published by Engage Healthcare Communications, LLC, 1249 South River Road, Suite 202A, Cranbury, NJ 08512. Copyright © 2015 by Engage Healthcare Communications, LLC. All rights reserved. Innovations in Oncology Management is a trademark of Engage Healthcare Communications, LLC. No part of this publication may be reproduced or transmitted in any form or by any means now or hereafter known, electronic or mechanical, including photocopy, recording, or any informational storage and retrieval system, without written permission from the publisher. Printed in the United States of America. The ideas and opinions expressed in Innovations in Oncology Management do not necessarily reflect those of the editorial board, the editors, or the publisher. Publication of an advertisement or other product mentioned in Innovations in Oncology Management should not be construed as an endorsement of the product or the manufacturers’ claims. Readers are encouraged to contact the manufacturers about any features or limitations of products mentioned. Neither the editors nor the publisher assume any responsibility for any injury and/ or damage to persons or property arising out of or related to any use of the material mentioned in this publication. POSTMASTER: Correspondence regarding subscriptions or change of address should be directed to CIRCULATION DIRECTOR, Innovations in Oncology Management, 1249 South River Road, Suite 202A, Cranbury, NJ 08512. Fax: 732-992-1881.
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The Payer Perspective
From a payer perspective, unexplained clinical variation in how physicians treat patients and utilize available healthcare resources is a major source of inefficiency. Several factors contribute to this variation in clinical care, including differences in medical specialty training programs, inconsistent payer practices, geographic differences, and a lack of specificity in treatment guidelines.8 Government and private payers are responsible for managing healthcare utilization and cost on behalf of healthcare purchasers, including public-sector and private-sector employers, employer coalitions, unions, and individuals. In recent years, payers have been seeking to understand their spending for cancer care, and there is a growing demand for consistency and reduced treatments that deviate from evidence-based clinical guidelines.9 Other approaches to understanding value and optimizing oncology care have been proposed, including administrative simplification, decision and technology support, improved data, and better alignment and consensus building between stakeholders. The oncology community, led by the American Society of Clinical Oncology (ASCO) Value in Cancer Care Task Force, has also joined in the value discussion.4 ASCO is embarking on a strategic initiative to define value in cancer care by developing a methodology for determining the relative value of cancer treatments and interventions. In its strategic initiative, ASCO seeks to ensure that oncologists have the skills and the tools needed to assess the relative value of interventions and to use them in discussing treatment options with their patients.4 Policy developments and economic pressures have provided fertile ground for collaboration between payers and providers of healthcare, including those in oncology. Several areas of collaboration can be identified within the oncology sector, including the development of clinical pathways or protocols, comprehensive care initiatives (eg, oncology medical homes), and other local efforts.
Clinical Pathways Programs
Collaborative efforts can be spearheaded by the payer or the practice. In order to improve the consistency of care that is provided to patients across providers, payers have been active in developing clinical pathways programs.10,11 In oncology, these programs target specific tumor types and extend to many cancers, including breast cancer, lung cancer, colon cancer, prostate cancer, and hematologic cancers, depending on the specific payer organization.11,12 A clinical pathway can be defined as a treatment road map of best care practices. Typically, pathways are developed based on an evaluation of research and medical evidence, including comparisons of efficacy, toxicity, and costs.13 Providers generally agree to a range of treatment options under certain clinical conditions. Acknowledging that the practice of medicine is not always an exact science, payers expect that participating providers will adhere to the clinical pathway approximately 80% of the time.11,14 In some cases, pathways programs have been driven by large
payer organizations that work with third parties to implement clinical protocols in arrangements with participating providers and provider organizations. For example, P4 Healthcare, an oncologist-led organization, has arrangements with several different national and regional insurers to implement programs at the local level.11 In a program that was implemented in 2010, CareFirst BlueCross BlueShield—a Maryland-based regional health plan— began paying oncology practices a bonus if at least 80% of their eligible patients were treated according to the P4 Pathways program for treatment and supportive care.11 The program included patients with breast cancer, lung cancer, colon cancer, prostate cancer, ovarian cancer, and 5 hematologic malignancies.11
In some cases, pathways programs have been driven by large payer organizations that work with third parties to implement clinical protocols in arrangements with participating providers and provider organizations. Aetna, a large national health insurer, has been active in the clinical pathways arena for several years, working with P4 Healthcare, Innovent Oncology, and other third-party partners.13 More recently, however, it has expanded its efforts, partnering with eviti to pilot a broader clinical decision support platform, with a complete database of treatment options that go beyond pathways.15 To support program implementation and facilitate data collection, Aetna is providing the software to its participating oncologists and will be linked to eviti in oncology offices through iNexx, Aetna’s health information exchange. That connectivity will allow practices to receive patients’ benefit information while channeling information on physician orders and treatment plans to Aetna.15
Comprehensive Care Initiatives
In contrast to clinical pathways programs, which are often initiated and implemented by payer organizations, other payer–provider collaborations have been spearheaded by oncology practices. In California, Wilshire Oncology Medical Group had focused on providing comprehensive care to its patients with cancer, including social, cognitive, and end-of-life support.16 In late 2000, patient cost-sharing began to increase rapidly, making high-quality oncology care more difficult for many patients to afford.16 In addition, Medicare reimbursement cuts and other cost-containment efforts by payers and third parties made it challenging for Wilshire to provide the comprehensive care it had championed. Seeing that its comprehensive care approach aligned with an emerging patient-centered medical home model, Wilshire launched its oncology medical home pilot in 2011.16
INNOVATIONS IN ONCOLOGY MANAGEMENT u 3
During that time, Wilshire started discussions with Anthem Blue Cross (formerly WellPoint), its largest local payer, demonstrating its value proposition for using more cost-effective regimens and preventing avoidable emergency department and hospital care.16 As a result of these discussions, Wilshire and Anthem agreed to initiate a pilot program to test Wilshire’s approach. During this process, the payers brought their medical director and actuary to Wilshire’s offices to see the operation, visit with the nurses and midlevel providers, and speak with patients.16 Because of legal issues and state regulations, it took time to get all the processes in place to launch the pilot. Ultimately, however, the payer was amenable to Wilshire’s approach and launched the pilot program.16 In Michigan, a similar collaboration took place between Priority Health, a regional health plan, and 5 community oncology practices.17 One participating practice, Cancer & Hematology Centers of Western Michigan (CHCWM), created an internal implementation team to work directly with Priority Health on the medical home program. Similar to other medical home initiatives, the Priority Health pilot included standardized treatment regimens and care management protocols. CHCWM and Priority Health worked collaboratively to identify the conditions that should be managed by the practice, but CHCWM was afforded the autonomy to create its own evidence-based protocols for each symptom and new processes to standardize care.17
Novel Pharmacy-Based Initiatives
One payer–provider collaborative effort addressed a more specific aspect of oncology management. In late 2013, Hematology– Oncology Associates of Central New York (HOACNY) approached Excellus BlueCross BlueShield, a prominent local payer, in an effort to bring the practice’s physician specialty dispensary in network.18 After several meetings, HOACNY was able to convince Excellus of its value proposition: that the personalized service provided by the practice would lead to improved patient satisfaction and better medication compliance.18 Dispensary staff members were active in helping patients in need secure financial assistance to help pay for expensive cancer medications.18 When shown the data, Excellus was impressed with HOACNY’s prowess in obtaining copay assistance for its patients and invited HOACNY to join its pharmacy network. As of May 2014, HOACNY had finished 3 months of filling all of Excellus patients’ oncology specialty medications.18
Conclusion
The health policy and financing landscape is bringing purchasers and providers of healthcare closer together in an effort to maintain and improve the high-quality healthcare that patients are accustomed to receiving. Payers are focusing on value and strategies for containing costs without compromising care. Because the costs of different cancer therapies often differ substantially,
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payers are seeking to maximize quality through the implementation of evidence-based clinical pathways and comprehensive care delivery platforms, such as the oncology medical home.13,16 The patient cost burden continues to rise,19 and, increasingly, the oncology medical community is recognizing that the current system of healthcare financing will become unsustainable.4 As the economic realities of escalating cost begin to threaten equal access to cancer care, providers and payer groups have begun to work together in several different collaborative arrangements. Today’s oncology practices should evaluate the value they bring to their patients and consider engaging local payers with value-based solutions that may prove to be mutually beneficial to both parties. u
References
1. Keehan SP, Cuckler GA, Sisko AM, et al. National health expenditure projections: modest annual growth until coverage expands and economic growth accelerates. Health Aff (Millwood). 2012;31:1600-1612. 2. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307:1513-1516. 3. Mariotto AB, Yabroff KR, Shao Y, et al. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011;103:117-128. 4. American Society of Clinical Oncology. ASCO in action brief: value in cancer care. January 21, 2014. www.asco.org/advocacy/asco-action-brief-value-cancercare. Accessed February 20, 2015. 5. Quintiles. Oncology drug development and value-based medicine. www.quintiles. com/~/media/library/white%20papers/oncology-drug-development-and-valuebased-medicine.pdf. Accessed February 20, 2015. 6. The Organisation for Economic Co-operation and Development. Why is health spending in the United States so high? 2011. www.oecd.org/unitedstates/ 49084355.pdf. Accessed February 20, 2015. 7. National Conference of State Legislatures. Health cost containment and efficiencies: NCSL briefs for state legislators. May 2011. www.ncsl.org/documents/ health/IntroandBriefsCC-16.pdf. Accessed February 20, 2015. 8. Dunn JD, Ellis PG, Fox JL, et al. Payer and provider collaborations that improve quality outcomes in oncology. Manag Care. 2010;19:35-40, 42. 9. Holcombe D. Oncology management programs for payers and physicians. Am J Manag Care. 2011;17(5 Spec No):e182-e186. 10. Mehr SR. Is Medicare ready for oncology clinical pathways? Am J Manag Care. 2014;20(2 Spec No):SP57-S58. 11. Greenapple R. Payers working collaboratively with providers to adopt clinical pathways and new care delivery models. J Oncol Pract. 2013;9:81-83. 12. Butcher L. Will clinical pathways work?: Insurers say they are willing to give up control over what they pay for to reduce cancer costs. But oncologists may think differently. Biotechnol Healthc. 2010;7:16-20. 13. Klein IM, Boccia RV, Cannon E, et al. Evolving strategies for the management of multiple myeloma: a managed care perspective. Am J Manag Care. 2014;20 (2 Suppl):s45-s60. 14. Neubauer M, Gosse N, Verrilli D, et al. Clinical pathways: are we there yet? Commun Oncol. 2013;10:96-98. 15. Reinke T. Insurers expand usefulness of oncology pathway efforts. Manag Care. 2013;22:9-10. 16. Wilshire oncology medical home pilot: reengineering cancer care. Value-Based Cancer Care. 2012;3:1,10-12,39. 17. Butcher L. Michigan payer initiates oncology medical home. Oncology Times. 2013;35:21-22. 18. Musselwhite T. Eye on ION: pursuing the second fill. Oncologistics magazine. 2014;13:1-42. 19. Fromer M. ASCO Post. Workshop explores growing problems in patient access to cancer drugs. July 10, 2014. www.ascopost.com/issues/july-10,-2014/iom-workshopexplores-growing-problems-in-patient-access-to-cancer-drugs.aspx. Accessed February 20, 2015.
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Innovations in Oncology Management
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To view and download past issues, go to
www.InnovationsInOncologyManagement.com Topics include: Part 1: Support Programs for Patients with Cancer in Need of Financial Assistance Part 2: Oral Chemotherapy Access Legislation: Impact on Oncology Practices and Their Patients
Good Manufacturing Process
Part 3: Emerging Payment and Delivery Models Part 4: Working Collaboratively with Local Payers
Future issues to include: Part 1: Navigating Payer Audits Part 2: Coordinating with Specialty Pharmacies Part 3: CMS Oncology Care Model Part 4: Navigating Legislative and Policy Directives
Supported by funding from Celgene Corporation and Celgene Patient Support. Manufacturer did not influence content. EHC388 Innovations ASize_040815
STAKEHOLDER PERSPECTIVE
Engaging with Local Payers: The Oncology Practice Perspective An Interview with Dawn Holcombe, MBA, FACMPE, ACHE, President, DGH Consulting, South Windsor, CT; Executive Director, Connecticut Oncology Association, South Windsor, CT
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ancer care, which can encompass inpatient treatment, imaging, diagnostics, office visits, pharmacotherapy, and end-oflife support, continues to increase in cost. As government and private payers seek to rein in the rising costs of care, there has been a clamor for consistency in patient care decisions and a reduction in treatments that deviate from evidence-based clinical guidelines. Health insurers thus continue to seek ways to eliminate waste and promote standardized care. Although oncology practices and providers can agree on the ultimate goal of efficient, patient-centered treatment, they may not, however, agree on the details of how oncology management should evolve. Within this landscape, oncology practices can take an active role to ensure that their interests are represented fairly in discussions with payer organizations, and that conversations with local payers are productive for all stakeholders. To further this discussion, Innovations in Oncology Management™ recently interviewed Dawn Holcombe, President of DGH Consulting and Executive Director of the Connecticut Oncology Association, who brings more than 30 years of management experience in hospital, system, network, and physician practices. She is a former president of the Medical Group Management Association’s Administrators in Oncology/ Hematology Assembly and a Fellow in the American College of Medical Practice Executives. In addition, she serves as the editor-in-chief of Oncology Practice Management and is on the editorial advisory board for Value-Based Cancer Care.
Q
Q: Describe the current climate for collaboration between payers and oncology practices, especially within the community oncology setting? Dawn Holcombe (DH): The climate is ripening, and I believe that oncology is where the true innovation is going to happen. In many ways, oncology is a microcosm of the entire healthcare arena. What we learn in terms of collaboration and managing our patients with cancer will translate to the larger healthcare landscape. There is going to be change in oncology management, and it is important that those who are treating the patients and those who are paying for their care are the ones sitting at the table.
Q
Q: There have been many well-documented efforts by payers and providers to come together at the corporate level; however,
6 u APRIL 2015
examples of successful organic collaboration at the local level are far fewer. What has your experience been? DH: Yes, there have been less local efforts for several reasons. In many markets the opportunity is limited because the majority of oncologists are hospital-based. Therefore the conversations are being held between the payer and the institution, rather than between the payer and the oncology practice. Also, it is not always clear to practice leadership with whom they should be speaking. Payers often delegate management responsibilities, and third-party companies are getting involved in decisions about appropriate oncology care. Several specialty pharmacies and pharmacy benefit managers are seeking to step into the arena as well. Regardless of other entities that may potentially be involved, I think that the practice should be speaking with the organization that is ultimately responsible, and typically that is the payer or even the employer. Local efforts have been limited to some degree, because the different parties do not know how to begin the dialogue.
Q
Q: How does an oncology practice begin to engage in collaboration with payer organizations or employers? How do they start the process? DH: It starts with smart baby steps. First, practices should conduct a preliminary internal assessment to identify the number of patients who are members or employees of the payer organization or employer with whom they wish to engage. A practice should not even knock on the door until they can answer that question internally. The practice also needs to understand its value portfolio: what is it about the practice that would make a potential partner want to work with it as opposed to somebody else? The practice must understand what that is and what it brings to the table before it starts the conversation with a payer or employer.
Q
Q: If a practice conducts this internal assessment and decides to move forward, how does it initiate the discussion with a local payer or employer? DH: First, the practice needs to define what it wants to discuss and create a framework to guide the discussion; therefore, devel-
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oping an agenda is critical. When creating this agenda, each party must think about the other party’s interests, not just about its own. The challenge is to develop an agenda that focuses on what the other party needs and wants—planning a meeting to say “I need to be paid more for what I do” will not lead to success. In my experience, the chance of success is greatly enhanced when the 2 groups are willing to put themselves in each other’s shoes and truly prepare for the conversation. The collaborative process unfolds gradually, and working together requires trust, which takes time to develop.
Q
Q: How do practices and payers determine where their interests align? DH: Any successful collaborative relationship must bring value to both parties. To understand value in this context, both parties need to look at the big picture, using the information that is available. Both sides have data that are crucial to painting the larger picture: the treating provider or institution has the detailed, patient-level clinical data, and the payer has the claims information with medical, pharmacy, and laboratory data. When you can marry these 2 sets of data, this is where you will get the information needed to move forward. Too many physicians or provider groups are still preparing to obtain information. In the hospital setting, data collection is often complicated by legacy information systems, which lack details regarding oncology specifics, making it difficult for those cancer centers to integrate clinical data. In some large cancer centers, there can also be huge billing systems that may be connected to the clinical data, but it is difficult to pull out the information that payers need.
Q
Q: Assuming that the conversations are productive and moving forward, at what point in the process will payers begin to involve their actuaries? DH: There should be enough relevant data on the table for the payer and the practice to be able to look at it and say, “This alignment makes sense.” Then, the payer and the practice will interpret that data for the actuaries to ensure that nothing gets missed. From a practice perspective, it is important that the discussion is not focused merely on drug costs. A comprehensive analysis should also account for potential medical cost offsets, such as reduced hospitalizations or emergency department visits. When the payers bring their actuaries to the table, it usually means that they are serious about working out an arrangement that is mutually beneficial to both parties. At that point, the conversations will have been productive, and the 2 groups will already have established a good comfort level and trust in working together.
Q
Q: In these types of discussions, which individuals represent the practice? DH: At a minimum, the managing partner, physician or physicians, and the chief practice administrator should be present.
The key clinical manager––typically the nursing administrator who sets up the clinical policies and procedures––should also be at the table. From the payer’s side, the medical director should be present in the beginning, along with the pharmacy director. Provider relations should also be represented. many of these collaborative efforts fail? QQ:DH:WhyBothdo sides need to be willing to compromise. Practices
should realize that they must take the steps that will help to meet the needs of the payer organization, and payers must be ready to offer reasonable incentives if the practice is willing to build consistency into their practice patterns. Discussing reimbursement from the onset is not going to get the practice very far.
Q
Q: We covered discussions at the practice level. Do state oncology societies become involved in these types of collaborative discussions as well? DH: Yes, state oncology societies have also participated in these discussions, including those in Michigan, Connecticut, Southern California, Alabama, and Florida, to name a few. Several state societies have been active in discussing clinical pathway launches on behalf of their member practices. For example, the state society in Alabama was actively engaging BlueCross BlueShield of Alabama about its different pathway programs in oncology. In addition, the Florida Society of Clinical Oncology is engaged in promoting the discussion of the business of oncology and the collaboration between payers and its members; we are doing the same in Connecticut. The societies themselves rarely have a direct financial stake in the outcome; however, they can play an important role in facilitating local discussions between payers and their member practices.
Q
Q: Are there any other examples of payer and community oncology collaborations that are currently taking place? DH: Yes, several discussions are ongoing. For example, Aetna, a large national health plan, conducted several pilots around tumor-specific clinical protocols, and it has identified what it would like to see in a practice that wants to come to the table. It has engaged in specific contracts with approximately 10 different practices and is in discussions with another dozen practices. Anthem (formerly WellPoint) and BlueCross BlueShield of Michigan have engaged in similar initiatives. However, the Anthem pathway rollout is meeting challenges in several of the states where it has been implemented, in part because it was built by the payer with limited input from the oncology community. As a result, providers are saying, “Wait, this is not exactly what we are comfortable with.” It all goes back to the importance of true collaboration. Despite these challenges, however, I expect to see more collaboration between oncology practices and payer organizations in the near future. u
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